Clinical Appeals RN

Confluence Health • Wenatchee, WA

87d • $39 - $61

About The Position

The Clinical Appeals RN will review and analyze denied and/or downgraded claims received from commercial, private and state payers. This role will utilize nursing and coding expertise to determine whether the claim should be appealed. For all applicable claims the RN will construct a compelling appeal letter based upon current coding guidelines, medical necessity of services rendered, as well as track and trend denial root causes.

Requirements

• Three (3) years of acute care experience or equivalent expertise and two (2) years' experience in utilization review.
• Proficient with Microsoft Office suite, internet and other systems (CMS, Government & commercial payor portals etc.).
• Analytical aptitude with the ability to collect, analyze and present data effectively.
• Must be a team-player and maintain a positive, resourceful attitude toward achieving the overall departmental and organizational goals.
• Strong attention to detail with excellent communication skills in both written and verbal forms.
• Ability to work independently and with limited supervision.
• Ability to communicate changes effectively, build commitment, and overcome resistance.
• Current licensure in the state of Washington (RCW 18.88) or licensure through Multistate Nurse Licensure Compact (SSB 5499).

Nice To Haves

• Bachelor's Degree.
• 2+ years experience working in the Epic system.
• Certified Coding Specialist (CCS).

Responsibilities

• Serves as the liaison with government and commercial payers to resolve complex claims, ensure favorable reimbursement, and address other billing or payment issues.
• Ability to write articulate and concise appeals by applying clinical knowledge, coding expertise and medical necessity.
• Ability to detect trends resulting in denials and constructively report on the root cause to assist in resolution and prevention.
• Responsible for evaluating likelihood of receiving a favorable resolution of medical necessity denials, payment discrepancies and contract misinterpretations.
• Responsible for clearly documenting actions taken in each patient account.
• Collaborates with physicians and interdisciplinary team as appropriate.
• Complies with the various payer rules regarding the appeal/denials process.
• Communicates with the patient access and billing teams as needed to facilitate appropriate actions for recoupment of denied/downgraded claims.
• Manages assigned workload of accounts so that appeals are submitted timely in accordance with payer timeframes.
• Performs other duties as assigned.
• Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.

Benefits

• Medical, Dental & Vision Insurance
• Flexible Spending Accounts & Health Saving Accounts
• CH Wellness Program
• Paid Time Off
• Generous Retirement Plans
• Life Insurance
• Long-Term Disability
• Gym Membership Discount
• Tuition Reimbursement
• Employee Assistance Program
• Adoption Assistance
• Shift Differential

What This Job Offers

• Industry: Hospitals